'Beyond BMI', new European obesity framework advises

A new European framework statement calls for consideration of measures other than body mass index (BMI) when diagnosing and classifying obesity.

The European Association for the Study of Obesity (EASO) consensus statement provides an algorithm for diagnosing and staging obesity based on clinical factors including BMI, adiposity, medical, functional, and psychological domains, and includes 28 consensus statements covering clinical staging and diagnosis, “pillars of treatment,” treatment goals, and initial levels of intervention.

“The incidence and prevalence of obesity are on the rise worldwide. Despite widespread recognition that obesity is a multifactorial and complex chronic disease, clinical recommendations guiding the diagnosis and management of obesity are not consistent with the clinical processes typically adopted for other chronic diseases. Moreover, effective new management approaches are emerging,” the authors wrote. Medscape Medical News.

As such, they state, “there is an urgent need to adapt the currently used framework for obesity management. A framework is needed that is more consistent with the conceptualization of obesity as a chronic disease based on adiposity. Importantly, we need to go beyond BMI to take into account abdominal adiposity, along with medical, functional and psychological disorders.”

statement It was released on July 5, 2024. Nature MedicineLead author is Luca Busset, MD, PhD, associate professor of medicine at the University of Padua in Padua, Italy. This is not a guideline, but a “framework on which to build guidelines,” Busset said.

New paradigm: Lowering BMI cutoffs and high waist-to-height ratios, cancer assessment

When reached for comment, W. Timothy Garvey, M.D., professor and director of the Diabetes Research Center at the University of Alabama at Birmingham, said: Medscape Medical News“I think this is a very concise and easy-to-understand document. Treatment is based on the progression of the disease and the patient's condition, i.e. the severity of complications. This is a Additional GuidelinesStarting with the Journal of the American Society of Clinical Endocrinology, [AACE] In 2016.”

But the framework has some new and notable elements, notes Garvey, lead author of the 2016 AACE guidelines: It calls for measuring waist-to-height ratio rather than just waist circumference, and it lowers the BMI cutoff to at least 25 kg/m.² It further states that a waist-to-height ratio above 0.5 “is associated with an increased risk of developing medical, functional, or psychological disorders or complications in adults of European descent.” The principle, with 65 percent agreement, is based on the recognition that even a low BMI can result in excess fat accumulation, the document states.

Also new are recommendations about evaluating people who may be at risk for sarcopenic obesity for it and about making sure that people who are obese get regular screening for obesity-related cancers, the latter of which “isn't in all the guidelines across the board, but it makes sense given what we know,” Garvey said.

According to the authors, “Refinishment of obesity diagnosis is currently underway. We hope that this new framework, together with other ongoing efforts, will contribute to improved obesity management in obese adults. We are confident that more detailed diagnostic parameters and possibly treatment algorithms will be developed in the future.”

Pillars of treatment await more data to allow for individualized guidelines

Seven of the 28 statements address the “pillars of treatment,” focusing on long-term, multidisciplinary management, including behavior modification for all obese patients, psychological therapy for some patients, obesity medications, and consideration of bariatric surgery.

The statement recommends prescribing medications as an adjunct to behavior modification according to approved labeling (BMI ≥ 30 kg/m ).² or ≥ 27 kg/m² The use of antiobesity medications is not recommended for patients with obesity-related diseases or comorbidities, but the authors suggest that antiobesity medications should be considered for adults of European descent with a BMI of 25 kg/m or greater.² Waist-to-height ratio greater than 0.5 and the presence of a medical, functional, or psychological disorder or comorbidity.

“Medication up to age 25 [BMI] “The scope is new. It recognizes that it's not just fat mass that's important, but the distribution and function of fat. Again, this is consistent with obesity-based chronic disease,” Garvey commented.

Garvey noted that the document lacks detailed treatment guidelines or detailed instructions on how to assess patients, and it doesn't discuss the social determinants of health or the bias and stigma surrounding weight that have been highlighted in recent studies. AACE Consensus Statement“Stigma can impair quality of life and even inhibit patients' adherence to treatment,” he noted.

Garvey said treatment guidelines will likely be updated as more data emerges about new drugs to treat obesity.

“We couldn't give a hierarchy of preferred drugs like we did with diabetes because we didn't have the data. But now, with second-generation obesity drugs, drug companies are conducting clinical trials with complications as the primary outcome,” he said. select, Step HFpEF, flowand Thermomount-OSA.

“They're showing that these drugs and the weight loss that comes with it have helped patients in important ways and reduced these complications. And as more data accumulates, we'll be able to recommend specific drugs for patients with specific complications.”

Garvey also said he hopes the document will help curtail the practice of online mail-order pharmacies prescribing new obesity medications by physicians who are licensed in a patient's state but do not examine the patient. “This is completely antithetical to obesity care as outlined in the EASO framework/algorithm. There is no examination, no clinical component of diagnosis, no assessment of obesity complications or associated diseases, and no possibility of comorbidity-centered treatment. Patients deserve better.”

The authors Medscape Medical News“Access to effective evidence-based management of obesity remains challenging. However, obesity is a chronic, relapsing disease that requires both an understanding of its multifactorial causes and accurate diagnosis…Adopting the framework will facilitate access to appropriate obesity management.”

Busset has received personal funding from Novo Nordisk, Boehringer Ingelheim, Eli Lilly, Pfizer, and Bruno Farmaceutici as an advisory board member, and from Rhythms Pharmaceuticals and Pronocal as a speaker. Other authors have disclosed industry information. Garvey provided expertise in the early stages of the statement's development but was not involved in its writing. He serves on advisory boards for Boehringer Ingelheim, Eli Lilly, Novo Nordisk, Pfizer, Fractyl Health, Alnylam Pharmaceuticals, Inogen, Zealand, Alion, Carmot/Roche, and Merck, and has conducted university-sponsored clinical trials funded by Novo Nordisk, Eli Lilly, Epitome, Neurovalence, and Pfizer. He also serves as an advisor to the nonprofit Milken Foundation.

Miriam E. Tucker is a freelance journalist based in the Washington, DC area. She is a regular contributor to Medscape Medical News and has also published work in The Washington Post, NPR's Shots blog, and Diatribe. You can find her at @MiriamETucker.